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When Caring for Patients Comes at a Cost: The Complex Reality of Chronic Hand Eczema · Amplify: A Podcast Powered by Patient Voice Partners

• 0:01
  SPEAKER_04: Welcome to Amplify, Elevating Patient Voices, a podcast powered by patient voice partners, where real stories spark bold conversations.
• 0:11
  SPEAKER_04: I'm Ursula Mann.
• 0:12
  SPEAKER_00: And I'm Brent Cordy.
• 0:14
  SPEAKER_00: Together, we're talking with patients, caregivers, and the healthcare change makers who are listening and taking action.
• 0:21
  SPEAKER_04: From personal journeys to policy shifts, these are the voices shaping a healthcare system that listens.
• 0:33
  SPEAKER_03: I'm here with my colleague Anne-Marie, and on today's show, we're going to be talking about chronic hand eczema with Dr.
• 0:40
  SPEAKER_03: George Cristadulo.
• 0:42
  SPEAKER_03: Today's episode is sponsored by Leo Pharma.
• 0:44
  SPEAKER_03: Leo is a global research-based pharmaceutical company that is dedicated to advancing the standard of care for the benefit of people with skin conditions, their families, and society.
• 0:54
  SPEAKER_03: Sponsorship helps support the Amplify podcast, but the conversation, perspectives, and final content are produced independently by Patient Voice Partners and our guests.
• 1:03
  SPEAKER_03: We want to say thank you to Leo Pharma for sponsoring today's episode.
• 1:07
  SPEAKER_03: And Dr.
• 1:08
  SPEAKER_03: George Cristidulo is a board-certified dermatologist and practices in Montreal.
• 1:14
  SPEAKER_03: Dr.
• 1:14
  SPEAKER_03: Cristillo is fluent in English, French, and Greek and practices general medicine and surgical dermatology with an additional interest in cosmetic dermatology and clinical research.
• 1:24
  SPEAKER_03: He primarily focuses on inflammatory disorders with a significant phototherapy practice as well as skin cancer screening and treatment.
• 1:32
  SPEAKER_03: I know in my conversations with him, there has been a lot about chronic canned eczema.
• 1:37
  SPEAKER_03: And for today, we're going to be talking about the complexity of diagnosis, current treatment limitations, and really what is out there for new innovation.
• 1:45
  SPEAKER_03: And what does it mean for access challenges when patients across Canada do not necessarily have the opportunity to be able to get the same treatment?
• 1:56
  SPEAKER_03: And it can vary depending on what province they are.
• 1:58
  SPEAKER_03: And Marie, I'm interested as you think about these topics, and we certainly talked about access for patients a number of times.
• 2:05
  SPEAKER_03: What comes to mind when you're thinking about chronic eczema?
• 2:09
  SPEAKER_02: Thanks, Ursula.
• 2:10
  SPEAKER_02: I think as I was thinking about this episode tonight and reflecting on some of the others in this series, I'm really curious about the art of clinical decision making and how it's evolving.
• 2:21
  SPEAKER_02: It's not just about data, it's not just about trials.
• 2:24
  SPEAKER_02: There's so many other things a clinician needs to consider.
• 2:27
  SPEAKER_02: And in this environment where patients are coming in with information coming from all kinds of different sources, we talked a little bit about reimbursement challenges.
• 2:37
  SPEAKER_02: We talk about workplace challenges.
• 2:38
  SPEAKER_02: And I think the clinician is in this place where he or she really has to weigh so many different things when they're having these conversations.
• 2:46
  SPEAKER_02: So I'm looking forward to having a conversation today to see what that kind of looks like and what that feels like and how it plays out in the clinic.
• 2:53
  SPEAKER_03: I really appreciate that, Maureen.
• 2:55
  SPEAKER_03: I think that's so thoughtful.
• 2:57
  SPEAKER_03: Any situation where diagnosis is complex is a challenge for treatment.
• 3:02
  SPEAKER_03: And I'm also interested to hear from Dr.
• 3:04
  SPEAKER_03: Cristadula the types of conversations patients raise with him, the questions they ask, and the sorts of things he brings forward to discuss with them as well.
• 3:14
  SPEAKER_03: So let's dive in.
• 3:15
  SPEAKER_03: And Dr.
• 3:16
  SPEAKER_03: Cristo Dula, I want to welcome you to today's show.
• 3:19
  SPEAKER_01: Thank you.
• 3:20
  SPEAKER_03: Thanks for being here.
• 3:21
  SPEAKER_03: So let's chat first about why diagnosis of chronic hand eczema is so complex.
• 3:28
  SPEAKER_03: What are some thoughts as to why it's often underdiagnosed, frequently missed, or misclassified?
• 3:34
  SPEAKER_03: How does this happen?
• 3:36
  SPEAKER_01: I think there's no very clearly agreed upon diagnostic criteria.
• 3:42
  SPEAKER_01: There's various types of hand eczema.
• 3:44
  SPEAKER_01: There's various causes of hand eczema.
• 3:46
  SPEAKER_01: It's like a very mixed bag disease that obviously affects patients significantly.
• 3:53
  SPEAKER_01: And there's a lot of different factors that come into this condition showing up in the first place.
• 3:59
  SPEAKER_01: Diagnosing it, you have this condition that's in front of you, but the background causes behind it are so varied and usually unclear.
• 4:08
  SPEAKER_01: You're just dealing with what you see in front of you.
• 4:10
  SPEAKER_01: And obviously, you're trying to figure out what caused it in the first place, but it's quite difficult because there's so many different causes.
• 4:16
  SPEAKER_01: Obviously, general guidelines that you suggest to patients, but it's not a very clear condition to diagnose in terms of like it's multifactorial.
• 4:25
  SPEAKER_01: I think that's the main conclusion.
• 4:26
  SPEAKER_01: It's just it's a multifactorial disease.
• 4:28
  SPEAKER_01: It's a chronic skin condition lasting usually three months or more, or that comes back multiple times a year.
• 4:35
  SPEAKER_01: That would classify it as a chronic hand eczema.
• 4:39
  SPEAKER_01: An eczema just means a disrupted barrier, but there's many types of eczema.
• 4:43
  SPEAKER_01: So it's a descriptive diagnosis.
• 4:47
  SPEAKER_03: I appreciate you sharing how important it sounds like a proper workup and history taking are essential.
• 4:54
  SPEAKER_03: In your clinical practice, have there been things that patients did a good job bringing up and articulating that really helped point you in the direction that this is chronic hand eczema?
• 5:04
  SPEAKER_03: And if so, can you share some of those that really it's a little bit of an aha moment?
• 5:08
  SPEAKER_03: You're like, this is a little bit more clear.
• 5:11
  SPEAKER_01: Well, I think the first thing is like establishing chronicity, right?
• 5:14
  SPEAKER_01: If someone comes in with a rash on their hands and it lasts just a couple of weeks, it doesn't fall into the chronic hand eczema stage.
• 5:22
  SPEAKER_01: And there is something that seems to happen over time in these patients to have some form of trigger.
• 5:27
  SPEAKER_01: And then over time they develop these chronic findings of their skin that just kind of self-perpetuate.
• 5:32
  SPEAKER_01: And so, like that, chronicity is really an important aspect into putting them in the bag of chronic hand eczema or putting them into the diagnosis that is that.
• 5:42
  SPEAKER_01: And then there's various factors that they might bring up in terms of their lifestyle or in terms of their history, like if they have a history of atopic dermatitis all over their skin, or if they have some workplace aspects that fall into the diagnosis, they go on vacation and it totally goes away and then go back to work, it starts again.
• 5:59
  SPEAKER_01: That can point to a more irritant or allergic cause, various things that they might be working with.
• 6:04
  SPEAKER_01: If they have any mechanical stress or something, that they're mechanics or something, they're using their hands, they're doing manual labor, they get rashes based on this, if it's seasonal, like all sorts of various supporting aspects that can help, I guess, cement that, yeah, contribute that diagnosis and try to help figure out not necessarily a cause, but like an aggravating factor that you can maybe try to pinpoint and decrease.
• 6:27
  SPEAKER_03: What are some of the symptoms that you find people commonly talk about in some of our other conversations?
• 6:33
  SPEAKER_03: So it's the itchiness, the flaking, the pain.
• 6:36
  SPEAKER_03: Are those the most common that you hear?
• 6:38
  SPEAKER_03: Or what do patients talk to you about most often for chronic hand eczema?
• 6:43
  SPEAKER_01: A lot of them talk about pain and cracking and itch and dry and flaky and crusting and all those uncomfortable words.
• 6:54
  SPEAKER_01: I think it's a bit more common to have itch in this condition than pain, but pain is also quite high up there.
• 7:02
  SPEAKER_01: And so this is a primarily itchy skin condition.
• 7:05
  SPEAKER_04: Those are difficult words to use.
• 7:07
  SPEAKER_01: Yeah, that's likely what happens.
• 7:09
  SPEAKER_01: What causes the quality of life metrics that we see with this disease?
• 7:13
  SPEAKER_02: Are there any things patients don't tell you that you wish they did, or things that you sometimes need to make them more comfortable before they're able to talk to you?
• 7:23
  SPEAKER_01: Honestly, I sort of ask questions based on what I see.
• 7:27
  SPEAKER_01: That's just maybe my way of doing things, and maybe others are different.
• 7:31
  SPEAKER_01: But when patients come with a certain rash or a lesion on their skin or whatever, like something just separate from this, you know, or this, I just want to give me a second, let me look at your skin first, and then we can get into the questions, you know?
• 7:44
  SPEAKER_01: Because it frames my thinking and it gives me a sort of a mind flow chart from which to work with.
• 7:50
  SPEAKER_01: And so then, based on seeing this kind of relatively evident diagnosis, but like a suggestive diagnosis, sometimes it's very evident, but sometimes it's not.
• 8:01
  SPEAKER_01: And seeing this in practice then gets you to start asking questions like what do you do for work?
• 8:07
  SPEAKER_01: Is it worse at work?
• 8:08
  SPEAKER_01: Does it get better when you leave work?
• 8:10
  SPEAKER_01: Did you work with any allergens, or do you use any specific allergens, perfumes, the irritants?
• 8:15
  SPEAKER_01: Do you wash your hands all the time?
• 8:17
  SPEAKER_01: Do you have eczema?
• 8:18
  SPEAKER_01: But I think the clinical picture dictates how I then ask questions.
• 8:22
  SPEAKER_01: So I do tend to direct the clinical visit because I want to get what I want to get for my diagnosis and treatment plan.
• 8:30
  SPEAKER_01: But then the other aspects that they mention starts becoming more in the sphere of quality of life.
• 8:35
  SPEAKER_01: And so that that provides like that extra just adds to that diagnosis, adds to the importance of diagnosis to that patient, because I can see something that I consider mild or moderate that it affects a patient so much more than another patient who I see, and I'm like, whoa, how are you living with this?
• 8:52
  SPEAKER_01: And they're just like, well, whatever, you know, life goes on.
• 8:56
  SPEAKER_03: Yeah, it is important.
• 8:58
  SPEAKER_03: What are some of the quality of life things that get brought up that patients bring up that you ask about?
• 9:04
  SPEAKER_03: What gets discussed?
• 9:05
  SPEAKER_01: Think about it, right?
• 9:06
  SPEAKER_01: Your skin is dry and itchy and cracked.
• 9:10
  SPEAKER_01: I literally cut my finger yesterday on a mandolin, give like a tiny little scrape.
• 9:16
  SPEAKER_01: And I'm like, this is really annoying.
• 9:19
  SPEAKER_01: Like really annoying to just wash your hands.
• 9:22
  SPEAKER_01: I'm holding a piece of pineapple and it's burning like the most minor cut.
• 9:27
  SPEAKER_01: Now, okay, fine, it's gonna heal and life goes on.
• 9:30
  SPEAKER_01: And I sort of haven't lost that hope that my skin is gonna go back to normal.
• 9:34
  SPEAKER_01: But like I can totally imagine a world if someone has this chronically that at some point it hurts so much, but they've just lost hope that it's gonna get better too.
• 9:43
  SPEAKER_01: So they just have to find a way to live with it.
• 9:46
  SPEAKER_01: Now, obviously, with time, the amplitude of symptoms start decreasing a little bit, your mind adapts to this sort of constant pain and itch, but like that still doesn't minimize the fact that you're still feeling those things all the time.
• 9:59
  SPEAKER_01: So if you're walking around with cracked hands that literally you go to shake someone's hand and it hurts you to just like form a handshaking symbol, okay, like hand movement, like that doesn't sound like a very good quality of life.
• 10:15
  SPEAKER_03: And flaking skin we heard about on top.
• 10:17
  SPEAKER_03: So you're shaking someone's hand, but the embarrassment factor, you can't avoid the handshake, and it's a social norm, but there's hesitancy.
• 10:25
  SPEAKER_03: So it's significant.
• 10:27
  SPEAKER_03: Thinking about current treatment and the role of innovation, you mentioned that you see people repeatedly where things progress and relapse is common with us.
• 10:37
  SPEAKER_03: So tell us a little bit about what you generally see in terms of overall, are the treatments working really well?
• 10:44
  SPEAKER_03: And has there been a lot of new options lately over the last little while to help people with this chronic hand eczema?
• 10:51
  SPEAKER_01: So, no, they're not working very well.
• 10:54
  SPEAKER_03: That's an easy answer, but not a happy one.
• 10:57
  SPEAKER_01: It's multifactorial.
• 10:59
  SPEAKER_01: It's not that it's not working well, it's that most of the time you can't always improve it to a very substantial degree.
• 11:06
  SPEAKER_01: And also there's access barriers for some patients, which we can always discuss as well as another factor as to why certain treatments don't work well.
• 11:15
  SPEAKER_01: But the thing is we have this mixed bag disease with multiple causes, and those causes include a dysfunction of your skin barrier and also inflammation.
• 11:27
  SPEAKER_01: So you need something that targets both of those, because if you just decrease the inflammation, well, you haven't necessarily fixed the skin barrier.
• 11:36
  SPEAKER_01: And if you help fix the skin barrier, but there's constant inflammation, then you're just restarting that cycle and then add behavioral components to it that obviously if you keep on scratching something, even if you try to improve it, it's just gonna recreate the same issue.
• 11:51
  SPEAKER_01: So you need to kind of stop that cycle.
• 11:53
  SPEAKER_01: And so there's multiple aspects going into care.
• 11:55
  SPEAKER_01: Usually, it's not like here, take this and you'll be good.
• 11:59
  SPEAKER_01: It's mix multiple different types of treatments.
• 12:02
  SPEAKER_01: I would say the mainstay of treatment is moisturizing and moisturizing with moisturizing creams that tend to maybe not be the most palatable creams because they're also the most effective, but they're also the least enjoyable to apply.
• 12:17
  SPEAKER_01: So that also affects compliance as well.
• 12:20
  SPEAKER_01: But doing that frequently, not just like once a day or twice a day, but like four or five, six times a day is helpful, but insufficient.
• 12:28
  SPEAKER_01: And so then you start getting into potentially more targeted treatments or anti-inflammatory treatments, and those don't always capture all patients.
• 12:39
  SPEAKER_01: They can help some, but there's some that it doesn't help.
• 12:42
  SPEAKER_01: And then you start having to use other medications that potentially cost a lot that may or may not help as well.
• 12:49
  SPEAKER_01: The point is you have a flowchart as to how to approach this, but it's not like take this and you're good.
• 12:55
  SPEAKER_01: There's multiple aspects going into treatment.
• 12:57
  SPEAKER_02: Can I ask a question about the creams?
• 12:59
  SPEAKER_02: When you say, you know, not that palette, is it the viscosity?
• 13:02
  SPEAKER_02: Is it rubbing off on things?
• 13:04
  SPEAKER_02: What is it that makes them difficult for patients?
• 13:08
  SPEAKER_01: There's various moisturizers that exist that are easy to apply and you put them on, and you don't feel like there's any form of film.
• 13:17
  SPEAKER_01: Especially on your hands, you're putting something and then you rub it in, you incorporate it, and then you kind of live your life, and you're using your mouse, and you see a layer of cream that just went on your mouse or on your keyboard.
• 13:28
  SPEAKER_01: Like that's very annoying.
• 13:30
  SPEAKER_01: But there's some creams that don't do that as much, okay?
• 13:33
  SPEAKER_01: But I would argue they also don't necessarily work as well.
• 13:35
  SPEAKER_01: Now, are they useless?
• 13:37
  SPEAKER_01: No.
• 13:38
  SPEAKER_01: But the ones that are more useful tend to be a little bit on the greasier side.
• 13:42
  SPEAKER_01: They have ingredients like glycerin, for example, that helps hydrate the skin and pulls water and helps block that water loss from your skin, but that's also kind of greasier, or ointments that totally help block water being released from your skin, like Vaseline style, and it's like very greasy.
• 13:59
  SPEAKER_01: So it's hard to use the stuff that works often enough to make a big difference unless you're really committed, or you just don't mind the texture.
• 14:08
  SPEAKER_03: Well, and it sounds like even if somebody is committed, or even if they're using them, because it's such a complex disease, many patients aren't experiencing significant improvement.
• 14:20
  SPEAKER_03: And then they can relapse as well.
• 14:22
  SPEAKER_03: And what worked one time may not work again as well.
• 14:27
  SPEAKER_01: Yeah, it's not sufficient.
• 14:29
  SPEAKER_03: So really the importance of new treatments coming to market continues to be important to be able to help this.
• 14:35
  SPEAKER_03: And for patients, we talked a little bit about the quality of life and the burden.
• 14:39
  SPEAKER_03: Have you had patients have to change work?
• 14:42
  SPEAKER_03: You mentioned earlier talking to them about triggers in the environment and what they're exposed to.
• 14:48
  SPEAKER_03: Have some shared with you financial challenges and what this means for them in their life as they're trying to manage everything?
• 14:55
  SPEAKER_01: Yeah, for sure.
• 14:55
  SPEAKER_01: I mean, there's some patients that would have to change work.
• 14:58
  SPEAKER_01: I think in one of the studies, it's something like 50% of patients have missed some form of work, which is pretty significant, 50, 60%.
• 15:07
  SPEAKER_01: And then a good proportion of patients have to change their actual job.
• 15:12
  SPEAKER_01: Now, that job change, I mean, think about it, depending on where you're living, may not necessarily be very easy.
• 15:19
  SPEAKER_01: You may not have a company, an employer, rather, that would be very understanding and potentially try to find a different position for you.
• 15:27
  SPEAKER_01: Some of these patients have an allergic contact dermatitis where they can actually get patch tested and they can get an actual proof that they have a workplace environment cause for this.
• 15:38
  SPEAKER_01: And then it starts becoming like a incubacle.
• 15:40
  SPEAKER_01: We have a C N E S S T, which is like the workplace sort of protective kind of whatever.
• 15:46
  SPEAKER_01: And then through that, you can go on to a disability and change jobs and kind of force employers to change your work and not fire you.
• 15:55
  SPEAKER_01: So that's a protective mechanism, which I think is essential and not available everywhere.
• 16:01
  SPEAKER_01: And so from that point of view, yes, that can facilitate a job switch, but that doesn't always happen.
• 16:08
  SPEAKER_01: You may not have an allergen, you may just have the condition in and of itself, but your job will irritate your skin further, and then you need a doctor's note, and maybe some doctors don't want to give it, or they don't want to get involved in like CSST forms that, like, for example, for us, or like forgetting all that, but like a patient doesn't want to change their job because they really like the job.
• 16:29
  SPEAKER_01: You're really happy with your job, and then your skin is just not letting you do it.
• 16:33
  SPEAKER_01: Imagine you have someone who's a nurse or a surgeon, or someone who is like a surgeon that's allergic to or that has like a constant irritant from having to scrub in all the time.
• 16:44
  SPEAKER_01: They can't not scrub in.
• 16:46
  SPEAKER_01: It's part of the job.
• 16:47
  SPEAKER_01: And stop operating, you know?
• 16:49
  SPEAKER_01: And so, like, how do you deal with that?
• 16:51
  SPEAKER_01: I don't know the right answer to that.
• 16:53
  SPEAKER_03: That's substantial.
• 16:54
  SPEAKER_03: Yeah, that's a huge work impact.
• 16:56
  SPEAKER_03: And it is a real challenging situation when treatment options aren't working.
• 17:02
  SPEAKER_03: And I didn't have chronic hand eczema, but it was a form of eczema.
• 17:06
  SPEAKER_03: And as a caregiver, we racked up a$1,500 bill on every cream that we could possibly find that didn't work.
• 17:12
  SPEAKER_03: So the importance of having new treatments be able to come to market for chronic hand eczema is understandably really important.
• 17:21
  SPEAKER_01: Let's also add to the fact that because of people's vulnerability, it also creates this kind of void of product kind of development that doesn't necessarily work, but is there to kind of prey on someone's vulnerability who's looking for any option that can work or try to help.
• 17:39
  SPEAKER_01: And so these things exist that provide promises of improvement, but that don't, but realistically just drain funds, like you just said,$1,500, you know?
• 17:49
  SPEAKER_01: Like, yes, there's over-the-shelf stuff, but there's stuff that are posted on Instagram in various places online as to, especially now with our algorithms, like best believe your phone knows you have that disease.
• 18:00
  SPEAKER_01: So you're gonna get those ads.
• 18:02
  SPEAKER_03: So, do you have patients often come to you having read the internet with requests for your opinion as to if this is sound information, if this is not advised and not a good idea?
• 18:14
  SPEAKER_03: Tell us a little bit about what they come in that you have to talk them out.
• 18:19
  SPEAKER_01: Well, I've had many patients that come in and say, I tried this cream, or oh, what do you think about this cream?
• 18:24
  SPEAKER_01: And they show me a page for a specific cream that is obviously not like a sort of a major brand thing.
• 18:31
  SPEAKER_01: Not to say that major brands aren't the only things that you can use, but it tend to have a little bit more data behind them.
• 18:37
  SPEAKER_01: And so they're showing me this that's like a five-ounce jar for like$60 or something that's just exorbitant compared to the actual prices of actual moisturizers that exist that are much more effective.
• 18:50
  SPEAKER_01: And then half the time you have to go into the fine print to find what the ingredients are.
• 18:54
  SPEAKER_01: And the majority of the time they have extracts, botanical extracts, essential oils, and those are known irritants or possibly allergens that effectively frequently worsen it.
• 19:08
  SPEAKER_01: And also when you have a disruptive skin barrier, you can actually create an allergy much more efficiently than if you don't.
• 19:15
  SPEAKER_01: So you can actually develop an allergic contact dermatitis by using some of these products that have a variety of botanical extracts and essential oils and then create an allergy and then My goodness.
• 19:27
  SPEAKER_03: I didn't know that.
• 19:28
  SPEAKER_01: That just makes it worse.
• 19:30
  SPEAKER_03: It makes it worse.
• 19:31
  SPEAKER_03: I'm glad people are asking you about this before proceeding or continuing.
• 19:35
  SPEAKER_03: That conversation's important.
• 19:37
  SPEAKER_01: I mean, the ones that are asking me are asking me.
• 19:39
  SPEAKER_02: That's a really important differentiator because it's not only that you're spending money on something that doesn't help, but you might actually be getting harmed by it.
• 19:48
  SPEAKER_03: Yeah, that's huge.
• 19:49
  SPEAKER_03: So as we think about innovation in this area and the importance of different options that you can prescribe, new creams, steroid-free topical things, different options that you have available.
• 20:00
  SPEAKER_03: It comes down to can people get it?
• 20:03
  SPEAKER_03: And what I'm referring to in Canada is the drug approval pathway process.
• 20:07
  SPEAKER_03: So it starts with Health Canada.
• 20:10
  SPEAKER_03: Health Canada will determine whether the drug can be marketed in Canada to provide regulatory approval.
• 20:15
  SPEAKER_03: And after that, two things happen in the rest of the provinces.
• 20:19
  SPEAKER_03: So there's Canada Drug Agency, and they evaluate evidence and they make reimbursement recommendations to public drug plans that are outside of Quebec.
• 20:29
  SPEAKER_03: And that helps inform funding decisions to move forward with PCPA, which is the Pan-Canadian Pharmaceutical Alliance, negotiations for again outside of Quebec.
• 20:41
  SPEAKER_03: Within Quebec, there is Inesse Dr.
• 20:44
  SPEAKER_03: Christadulo.
• 20:45
  SPEAKER_03: Do you know what INESA stands for?
• 20:47
  SPEAKER_01: Institut National d'Excellence en Santé et Services Sociaux.
• 20:51
  SPEAKER_03: Inesse evaluates drugs for Quebec and it provides recommendations to the minister regarding listing and reimbursement under Quebec's drug plan.
• 21:00
  SPEAKER_03: Now, what I've mentioned refers to the public drug plans.
• 21:04
  SPEAKER_03: The other options for people are private drug plans if somebody is working.
• 21:09
  SPEAKER_03: And the third option is after Health Canada approves a drug, if it's available on the market, is to cash pay for a medication.
• 21:16
  SPEAKER_03: So one of the things that we unfortunately see commonly across Canada is that people living in different provinces don't necessarily have access to the same medications.
• 21:29
  SPEAKER_03: And Dr.
• 21:30
  SPEAKER_03: Costadulo, if you can think of chronic hand eczema and what this means to patients that you're treating, how do you react as a practicing physician that some treatment options may not be available in Quebec that are available in other provinces?
• 21:45
  SPEAKER_01: I think in general, I would say not always, but in general, the public coverage for some of these medications tends to be mirrored between provinces, at least in Quebec and for example.
• 22:00
  SPEAKER_01: Ontario.
• 22:00
  SPEAKER_01: Now BC's is sort of a whole other story.
• 22:03
  SPEAKER_01: I know that they have a lot less coverage for certain biologic medications and all this.
• 22:07
  SPEAKER_01: So I can't pretend to know the intricacies of all provinces.
• 22:10
  SPEAKER_01: I'm maybe a little bit more familiar with Ontario just because it's close to me.
• 22:14
  SPEAKER_01: But tends to be a mirroring of coverage, but not always.
• 22:18
  SPEAKER_03: I'm going to sidebar for a sack just to fill you in a little bit.
• 22:22
  SPEAKER_03: So if it does happen and NASA's negative, CDA is positive, I guess this did happen in chronic hand eczema.
• 22:29
  SPEAKER_03: So that means publicly you can't move forward with it.
• 22:32
  SPEAKER_03: Private to be determined, you can cash pay, but it's a real differential situation.
• 22:39
  SPEAKER_03: And they're looking at the same data.
• 22:41
  SPEAKER_03: So at times we have seen for different medications that between these two bodies, Canada Drug Agency and Inesse, they receive submissions from manufacturers.
• 22:51
  SPEAKER_03: They don't always necessarily come to the same conclusion, which impacts what happens after.
• 22:57
  SPEAKER_03: What are your thoughts on whether people live in different provinces, what this means to them as their treatment care can be impacted if they were to be covered under government plans?
• 23:10
  SPEAKER_01: So I mean, in terms of patient awareness, I don't know that patients are entirely aware that like a treatment is covered in another province and not covered in theirs.
• 23:20
  SPEAKER_01: So as much as we are a country with multiple provinces, it is a little bit siloed in that respect.
• 23:26
  SPEAKER_01: And so I haven't gotten patients saying that because it's not covered here, that oh, it's covered in another province.
• 23:31
  SPEAKER_01: That doesn't usually happen.
• 23:34
  SPEAKER_01: However, in reality, that does mean that they don't get access to it.
• 23:39
  SPEAKER_01: So they're not necessarily aware of the difference, but the result is the same.
• 23:45
  SPEAKER_01: So these patients don't get access to some of these medications, and then they have to decide what to do.
• 23:51
  SPEAKER_01: Some patients can't afford it at all.
• 23:54
  SPEAKER_01: Some patients can afford it.
• 23:55
  SPEAKER_01: A lot of these companies have sort of first tube free kind of thought stories that you could try to see if it actually works so it and minimizes like the outright payment.
• 24:04
  SPEAKER_01: And so maybe they might want to pay for an after just based on the fact that they see that it's an effective treatment.
• 24:09
  SPEAKER_01: But these are expensive medications.
• 24:11
  SPEAKER_01: Now we've had a huge boom over the past two to three years of these non-steroidal options that provide a whole other host of possibilities in terms of treatments, especially long-term treatments without the risk of topical steroids.
• 24:26
  SPEAKER_01: However, they do come at a very premium price, depending on which one you're looking into.
• 24:32
  SPEAKER_01: And so unfortunately, if these topical medications are not covered by governmental plans, then you start really getting this two-tiered medical system.
• 24:40
  SPEAKER_03: For sure.
• 24:41
  SPEAKER_03: And do you find yourself having some conversations with patients as you're prescribing or talking about treatment options as to cost to determine what might be the best option?
• 24:52
  SPEAKER_01: For sure.
• 24:53
  SPEAKER_01: One of my first questions is do you have insurance?
• 24:55
  SPEAKER_03: Okay.
• 24:56
  SPEAKER_01: I hate having to ask this question, but it's one of my first questions.
• 24:59
  SPEAKER_03: Yeah, I've been on the receiving end of that question, and I know what I'm getting prescribed is different if I say yes.
• 25:06
  SPEAKER_01: Because it literally defines my treatment options afterwards, or at least like my initial treatment options.
• 25:12
  SPEAKER_01: I might be more likely to progress right away to a more advanced treatment option if someone has insurance, because the likelihood is a little bit higher that it might work, or I think it's a better treatment option for that patient, but it's not if they don't have insurance because of the fact that it won't be covered.
• 25:28
  SPEAKER_01: And so then they have to go through other steps, extend the life of their disease, possibly never get to a point of control because we may never get to that point because they can't afford it.
• 25:39
  SPEAKER_01: And so it creates that two-tiered system, unfortunately, where patients that don't have insurance are not getting the best level of care that they can.
• 25:47
  SPEAKER_01: On the other hand, I do understand to an extent the fact that these require a significant amount of research and development and clinical trials now compared to when they were 20 plus years ago are becoming exceedingly expensive.
• 26:01
  SPEAKER_01: And it's also becoming a lot more difficult to also recruit patients.
• 26:04
  SPEAKER_01: The tools are getting smaller and the costs are getting bigger, and these sort of checkpoints are getting bigger within the clinical trials.
• 26:10
  SPEAKER_01: And so these end up ballooning costs of these clinical trials.
• 26:13
  SPEAKER_01: And so obviously, you're going to get these medications that cost more, relatively speaking, but that still doesn't change the fact that they're very expensive.
• 26:22
  SPEAKER_02: Yeah.
• 26:22
  SPEAKER_02: I really appreciate thank you for being honest about how you feel about having some of these conversations.
• 26:28
  SPEAKER_02: Ursula and I were chatting as we were preparing for the episode.
• 26:31
  SPEAKER_02: We were chatting a little bit about some of the ethical considerations when you are having some of these conversations.
• 26:37
  SPEAKER_02: And I've heard some physicians express a lot of discomfort that I feel like it's unethical for me to tell someone about a treatment that I know they can't afford and is not covered.
• 26:50
  SPEAKER_02: And then on the flip side, I feel it's unethical not to tell folks about treatments that might help them, regardless of affordability.
• 26:59
  SPEAKER_02: And it places you as a clinician in a really difficult position.
• 27:03
  SPEAKER_02: It sounds like you're more inclined to have the conversation with your patient.
• 27:08
  SPEAKER_02: Is that what I heard?
• 27:09
  SPEAKER_01: Well, I think it adds a little bit of extra work and on this on a clinician that they can't just prescribe a medication outright.
• 27:17
  SPEAKER_01: I do have certain treatment options available at my clinic.
• 27:20
  SPEAKER_01: I have phototherapy machines that tend to be a good bridge between treatment and might actually improve a good amount of these patients.
• 27:27
  SPEAKER_01: And that's a covered service.
• 27:29
  SPEAKER_01: So that's not something that they have to pay for.
• 27:31
  SPEAKER_01: So I have helped a lot of patients through that without them having to use certain creams, but like, well, find a way.
• 27:37
  SPEAKER_01: I usually find a way.
• 27:39
  SPEAKER_01: It's just a question of it's not always easy.
• 27:41
  SPEAKER_01: And sometimes you have to cut some corners.
• 27:44
  SPEAKER_02: Takes time and effort, yeah.
• 27:46
  SPEAKER_01: And make it work somehow.
• 27:48
  SPEAKER_02: Thank you for going that extra for your patience, because I know patients appreciate it.
• 27:54
  SPEAKER_03: You said something that really struck me, and that was extend the life of the disease.
• 27:59
  SPEAKER_03: And that's such a challenge to hear.
• 28:02
  SPEAKER_03: I know we're all on the same side.
• 28:03
  SPEAKER_03: We're wanting to extend the life of the remission if something is chronic and happening.
• 28:09
  SPEAKER_03: What have you heard from patients about what they do in situations where they perhaps have heard of a treatment, they can't get it where they are, what actions they can take or how they connect with the patient group that is working in this area and helping to educate around the quality of life, the challenges of living with this, the importance of being able to have different treatment options.
• 28:36
  SPEAKER_03: What are your thoughts?
• 28:37
  SPEAKER_01: I think it's important to have some form of support group when it comes to a chronic condition because it normalizes the condition a little bit, knowing that other people have it.
• 28:46
  SPEAKER_01: So it creates a bit of a sense of community.
• 28:48
  SPEAKER_01: You do have to be a little careful because some people will say, Oh, I tried this or oh, I tried that.
• 28:53
  SPEAKER_01: So that's sort of the N of one kind of sample size of this works for me, doesn't necessarily work for everyone.
• 28:58
  SPEAKER_01: But that still doesn't change the fact that having a community around this is quite helpful and essential.
• 29:04
  SPEAKER_01: Obviously, sometimes patients come in expecting a certain type of treatment.
• 29:08
  SPEAKER_01: I haven't necessarily gotten this very much with chronic honey eczema.
• 29:12
  SPEAKER_01: I get it a lot with eczema and psoriasis of the body, more so than chronic honeczema, which they saw an ad on TV or like their friend is using it or whatnot, and they kind of ask me about the treatment, and I tell them all, you know, there are certain criteria that we have to pass to get to that for there to be coverage.
• 29:28
  SPEAKER_01: And so people do have to pass through hoops.
• 29:31
  SPEAKER_01: But I'll turn the question around a little bit and bring up a notion that's been brought up more and more in the literature called cumulative life course impairment.
• 29:41
  SPEAKER_01: And so this is something that exists, especially when it comes to eczema or atopic dermatizer and psoriasis, and obviously more so for younger patients than older, but still for older patients.
• 29:52
  SPEAKER_01: The basis of this is that the longer you have a specific disease, the more likely that disease is to affect you in various ways, which will then affect your life decisions and life course, and that will compound over time.
• 30:12
  SPEAKER_01: So it's a little bit of an easier thing to see in a child, for example, where you might have very bad eczema that prevents them from concentrating in school or sleeping.
• 30:23
  SPEAKER_01: And so then they develop at a potentially slower rate, and then they increase the risk of getting anxiety over time or concentration difficulties, difficulties in school, and that can kind of lead to fewer social connections and development and progression throughout life and achievements and grades and stuff like that, has this accumulative impairment.
• 30:46
  SPEAKER_01: Same thing for adults when it comes to work.
• 30:49
  SPEAKER_01: If you have a skin condition that affects your work, you maybe you're missing work, you're less likely to get promoted, you're less likely to have social relationships, romantic relationships, et cetera.
• 30:59
  SPEAKER_01: Like all these things accumulate, more likely to get depressed, more likely to get anxious.
• 31:03
  SPEAKER_01: So when you have a condition, all this to say that when you have a condition that lasts longer, all you're doing is accumulating these dinks on yourself.
• 31:14
  SPEAKER_03: And that's an accumulation of stress.
• 31:16
  SPEAKER_03: And you mentioned earlier that the percentage of people that have to take time off work.
• 31:21
  SPEAKER_03: And now you highlighted the impact of that, you know, the performance, the time off.
• 31:25
  SPEAKER_03: I don't think that's something employers are necessarily thinking of top of mind in terms of, you know, my employee is going to be off if they're not well.
• 31:34
  SPEAKER_03: And so the more we can limit that time of the disease, the better options for people.
• 31:40
  SPEAKER_03: Certainly, this is a complex area.
• 31:43
  SPEAKER_01: Well, it's not like as if you have a disease and while you have this disease, things just you press pause and then your disease is over and you press play.
• 31:51
  SPEAKER_01: It's like there's a significant deterioration over time of just life.
• 31:56
  SPEAKER_02: And I think the reality is as well that these multifactorial impacts that people live with are often handled or worked through with very different, right?
• 32:08
  SPEAKER_02: So it becomes that siloed care again.
• 32:11
  SPEAKER_02: And we still haven't really figured out that way to really integrate care for the whole person.
• 32:18
  SPEAKER_02: Right.
• 32:18
  SPEAKER_01: Well, some people are more resilient than others, right?
• 32:21
  SPEAKER_01: And so this condition might have a disproportionate impact on one person and not really affect someone else.
• 32:28
  SPEAKER_01: And the longer you have it, the more that will affect that person, that patient.
• 32:33
  SPEAKER_03: So this has been a really important conversation around the complexity of diagnosis of chronic hand eczema and how we need to be thinking of what people can have access to to hopefully keep themselves as healthy as possible and continue in their work and even the access considerations that people don't necessarily have the same treatment options once a decision is made within that reimbursement process.
• 33:00
  SPEAKER_03: So I want to say thank you for such thoughtful reflections as a prescribing clinician, seeing so many of these patients to have these difficult conversations around quality of life and the disease management and subsequent treatment.
• 33:13
  SPEAKER_03: This has been very thoughtful.
• 33:15
  SPEAKER_03: And to end on a fun note, interested, what's around the corner for you?
• 33:20
  SPEAKER_03: And we understand you have a really fun trip coming up to France.
• 33:23
  SPEAKER_03: Tell us what you're most excited about.
• 33:25
  SPEAKER_01: We're going to my sister-in-law's wedding, my wife's actual sister.
• 33:30
  SPEAKER_03: Fabulous.
• 33:31
  SPEAKER_01: And so they have a wedding in France in Uth Village that's a little bit off the beaten path, but certainly not a very popular place.
• 33:37
  SPEAKER_01: And so it's a little bit more countryside, so it should be quite nice.
• 33:40
  SPEAKER_01: But we're taking our two kids.
• 33:46
  SPEAKER_03: Oh wow.
• 33:47
  SPEAKER_01: You know, I'm excited, but also like a little bit nervous.
• 33:51
  SPEAKER_03: Yeah.
• 33:51
  SPEAKER_01: Hey, that's going to be some management, you know, but we'll figure it out.
• 33:54
  SPEAKER_01: We'll figure it out.
• 33:56
  SPEAKER_03: Oh, it's beautiful.
• 33:57
  SPEAKER_03: Well, wish you the best of travels and the baguette and cheese and wine is a lovely combination over there.
• 34:05
  SPEAKER_03: So enjoy the countryside and I hope it's a wonderful wedding and wishing you a wonderful trip.
• 34:10
  SPEAKER_01: Thank you.
• 34:10
  SPEAKER_01: I'm sure it will be.
• 34:11
  SPEAKER_03: Thank you for this thoughtful conversation today on chronic hand exam and all the considerations.
• 34:16
  SPEAKER_03: Thanks for being with us.
• 34:18
  SPEAKER_01: You're welcome.
• 34:18
  SPEAKER_01: Thank you guys.
• 34:19
  SPEAKER_01: Thanks for having me.
• 34:20
  SPEAKER_03: Also want to say special thanks today to Leo Pharma for sponsoring this episode of Amplify.
• 34:31
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• 34:36
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• 35:04
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• 35:14
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• 35:16
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